A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?
Obtain filterless IV tubing.
Place the blood in a warmer for 1 hr.
Use a 24-gauge IV catheter.
Prime IV tubing with 0.9% sodium chloride.
The Correct Answer is D
Rationale:
A. Obtain filterless IV tubing: Blood transfusions require specialized IV tubing with an in-line filter to remove clots and debris. Using filterless tubing would increase the risk of transfusing particulate matter into the client’s bloodstream.
B. Place the blood in a warmer for 1 hr: Blood should only be warmed if specifically prescribed and done using an approved device immediately before administration. Prolonged warming increases the risk of bacterial growth and hemolysis.
C. Use a 24-gauge IV catheter: Packed RBCs should be administered through a larger-bore catheter (typically 18–20 gauge) to allow adequate flow and prevent hemolysis. A 24-gauge catheter is too small for efficient transfusion.
D. Prime IV tubing with 0.9% sodium chloride: Normal saline is the only compatible solution for priming and administering blood products. It prevents clotting and hemolysis while ensuring that the blood flows freely without interacting with other IV solutions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B,D,C,A
Explanation
Rationale:
B. Place the child in a sitting position: Positioning the child upright or with the head slightly tilted back promotes comfort, stability, and proper visualization of the conjunctival sac for accurate drop placement.
D. Pull the lower eyelid downward: This creates a conjunctival pocket that holds the medication and allows it to spread evenly over the eye surface without spilling.
C. Instill the drops of medication: Instillation should occur after exposing the conjunctival sac to ensure the medication reaches the target area. The dropper should not touch the eye to prevent contamination.
A. Apply pressure to the lacrimal punctum: This step is performed last to prevent systemic absorption of the medication by blocking the nasolacrimal duct. Holding gentle pressure for about 1 minute helps maximize the local effect of the drops.
Correct Answer is B
Explanation
A. Teach the client relaxation techniques: Teaching coping strategies is helpful but does not address the immediate need to understand the client’s perception of the crisis. It should follow assessment.
B. Confirm the client's perception of the event: The first step in crisis intervention is to assess and understand the client’s view of the situation. Clarifying perception allows the nurse to accurately prioritize interventions and provide appropriate support.
C. Notify the client's support person: Contacting support is beneficial for ongoing assistance but should occur after assessing the client’s understanding and emotional state.
D. Help the client identify personal strengths: Identifying strengths promotes coping and resilience, but it is a secondary intervention that should follow assessment and clarification of the client’s perception.
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